Doctors and patients speak with one voice to mark World Patient Safety Day
Published: 16 Sep 2022
The Doctors Association UK and the patients’ charity Action against Medical Accidents have agreed the following joint statement and call for action to coincide with World Patient Safety Day (17th September 2022).
Dr Jenny Vaughan (‘Learn Not Blame’ Lead for Doctors Association UK) and Peter Walsh (Chief Executive of Action against Medical Accidents) said:
“There are hundreds of thousands of incidents resulting in avoidable harm and deaths to patients in the NHS every year. Whilst there will always be some things that go wrong in such a vast, complex and risky activity as healthcare, this is far too many. There is no one ‘golden bullet’ solution, but we, as representatives of doctors and patients, are calling on the Government and the NHS to address two key issues as a matter of urgency.
1. Sufficient resources need to be allocated to the NHS. Too many NHS settings are understaffed and there are shortages of key personnel. Add poor morale into the mix and this is a disaster waiting to happen. No doctor (or other health professional) should be in a position where they have to work unreasonable hours or in such stressful, under-staffed and unsafe environments. It is not fair to doctors, and it is not fair to patients. It is also a false economy, as it leads to avoidable harm and deaths and all the human and financial collateral damage that follows.
2. A genuinely ‘Just Culture’ needs to be developed and supported across the whole health and social care system including the respective UK departments of health and social care and regulators. Such a culture needs to apply equally to all health professionals and to patients and their families.
We both support the principles of ‘Learn Not Blame’ published by the Doctors Association UK. Doctors (or other health professionals) should not be blamed or ‘hung out to dry’ for system failures. There needs to be full corporate responsibility allowing the circumstances which bring these failures about. Health staff should be supported through the trauma of having been involved in an incident that led to harm. Rarely, there should also be individual accountability when a health professional is intentionally reckless or unable to perform their duties safely. Consequences must be fair and proportionate.
We both support the principles of ‘What Just Culture should look like’ published by Action against Medical Accidents. The NHS has a moral duty of care to patients who have been harmed or their families. Provision must be made to provide different kinds of support for harmed patients or their families as described in the ‘Harmed Patient Care Pathway’. Patients/families have a right to know the truth and be assured that lessons will not only be learnt but acted upon. Legal redress is a recognised part of this process. It can be an important safety net when matters can not be resolved in less adversarial ways. Diminishing access to justice for people affected by healthcare harm or a doctor’s right to defend themselves from allegations they consider invalid is unacceptable in a ‘just culture’.
Just culture should apply from top to bottom of the health and social care system. This means national as well as local health and social care policy and practise having to be in accordance with just culture principles.
On behalf of both doctors and patients we call on UK governments and the NHS to address these issues as a matter of urgency.”